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Waste Tire Sur . Jy & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181( ew 04104) <br /> California Integrated WasteManagement Board Survey Form - Page 1 . I1 - 1127636 <br /> Part A- Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I y l.J *Routine Q Re-inspection Q Referral Q Observation <br /> Local n ��� If Referral,choose referral type(Fill one) <br /> Identifier: XXL ��.XX,,��,�� CJY�r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physi I Address 9 - Q /4 <br /> ,L.). �yl �` <br /> t-sgoo 1'}r,(,eJanZx' 6 rib <br /> R Inspection Date O <br /> �� � ��' FJ��-���s Time In Time Out <br /> Business Rep L Title ) ® AM 0 AM <br /> Aice\ 6e,. l yizoti A-Ce' c- 1 -i 5, Q PM l lJ ( PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (�/ 4 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger ® Generator 40 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other Hui0rt✓ve1_ fG <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ® Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / M16 <br /> Q Q 114 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> I® Q 114 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - _ _... <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: �I <br /> Comments Included: - I <br /> siness a 's ignat a one Number s ctor' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I ; it ! I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink <br />